Fillable Printable Application for Employment - CareSouth of Carolina

Application for Employment - CareSouth of Carolina

CareSouth Carolina, Inc. APPLICATION FOR EMPLOYMENT

P.O. Box 1090, Hartsville, SC 29551

843-857-0111 (PLEASE PRINT) Date:

LAST NAME FIRST NAME MIDDLE

ADDRESS: STREET CITY STATE ZIP CODE

TELEPHONE NUMBER(S) SOCIAL SECURITY NUMBER

POSITION(S) APPLIED FOR: ________________________________________________________________________________________________

HOW DID YOU LEARN ABOUT US? ❒ ADVERTISEMENT, ❒ FRIEND, ❒ WALK-IN, ❒ RELATIVE, ❒EMP AGENCY, ❒ OTHER ___________

If you are under 18 years of age, can you provide required proof of your eligibility to work? ❒ Yes ❒ No ❒ N/A

Have you ever filed an application with us before? ❒ Yes ❒ No If yes, give date ____________________________

Have you ever been employed with us before? ❒ Yes ❒ No If yes, give date ____________________________

Are you currently employed? ❒ Yes ❒ No May we contact your current employer? ❒ Yes ❒ No

Are you prevented from lawfully becoming employed in this country because of Visa or Immigration status? ❒ Yes ❒ No

(Proof of citizenship or immigration status will be required upon employment.)

On what date would you be available for work? ______________________ ❒ FT ❒ PT ❒ Temporary (PRN)

Can you travel if a job requires it? ❒ Yes ❒ No Are you currently on “lay-off” status and subject to recall? ❒ Yes ❒ No

Have you been convicted of a felony within the last 7 years? ❒ Yes ❒ No (Conviction will not necessarily disqualify you from employment.)

If yes, please explain: _______________________________________________________________________________________________

EDUCATION

Name and Address of School Course of Study Years Completed Diploma/ Degree

Elementary

School

High

School

College or

Technical School

Graduate/

Professional

Describe any specialized training, apprenticeship, skills and extra-curricular activities that would enhance your qualifications.

We consider applicants for all positions without regard to race, religion, color, creed, gender, national origin, age, disability, marital or veteran status, or

other legally protected status.

EXPERIENCE

Start with your present or most recent job. You may exclude organizations that indicate race, color, religion, gender, national origin, disabilities, or other

protected status.

Employer From - To Position

Address Job Duties

Telephone Number Verified (by HR)

Employer From - To Position

Address Job Duties

Telephone Number Verified (by HR)

Employer From - To Position

Address Job Duties

Telephone Number Verified (by HR)

APPLICANT’S STATEMENT

I certify that the answers given herein are true and complete to the best of my knowledge.

I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.

This application for employment shall be considered active for a period of time not to exceed 90 days. Any applicant wishing to be considered for

employment beyond this time period should inquire as to whether or not applications are being accepted at that time.

I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an “at

will” nature, which means that the employee may resign at any time and the employer may discharge an employee at any time with or without cause. It

is further understood that this “at will” employment relationship may not be changed by any written document or by conduct unless such change is

specifically acknowledged in writing by an authorized executive of CareSouth.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I

understand also that I am required to abide by all rules and regulations of CareSouth.

Signature of Applicant _________________________________________________ Date ___________________________________

Revised September 30, 2009 at 2:00 PM